Chapter 10 Diabetes and the Status Aboriginal Population in Alberta

ALBERTA DIABETES ATLAS 2009 189

Richard T. OsterBrenda R. HemmelgarnEllen L. TothMalcolm KingLynden CrowshoeKelli Ralph-Campbell

Chapter 10 Diabetes and the Status Aboriginal Population in Alberta

190 ALBERTA DIABETES ATLAS 2009


CHAPTER 10

DIABETES AND THE STATUS ABORIGINAL POPULATION IN ALBERTA

KEY MESSAGES

• DiabetesismuchmorecommonamongtheStatusAboriginalpopulation,asincidenceandprevalenceratesaretwiceashighinbothmalesandfemalescomparedtothegeneralpopulation.

• From1995-2007,therateofincreaseinincidenceofdiabetesforStatusAboriginalpeoplewasslowerthanforthegeneralpopulation.

• AmongStatusAboriginalpeople,theprevalenceofdiagnoseddiabetesishigheramongfemalescomparedtomales,butthemaleincidenceratehasincreasedtoequalthefemaleincidencerate.

• Themortalityrateratio(DMtonoDM)washigherforthegeneralpopulationcomparedtoStatusAboriginalsforallagegroups.

• Useofhospitalandemergencydepartmentservicesis2to3timeshigherfortheStatusAboriginalpopulationwithdiabetescomparedthegeneralpopulation.

BACKGROUND

ForCanadianAboriginalpopulations,initialcontactwithEuropeansresultedinsociallymediatedstressfrominfectiousdiseasesandstarvation.(1)However,thepast100yearshavebroughtaboutanepidemiologicalshiftinprevailinghealthissues,givingwaytochronicdiseases,suchasobesity,type2diabetes(DM),cancerandcardiovasculardisease,experiencedinanacceleratedfashionoverafewgenerations.(1,2)Nationalestimatesfromthe“1999FirstNationsandInuitRegionalHealthSurvey”showeddiabetesprevalenceratestobe8%and13%forFirstNationsmenandwomen,respectively,(3)or3to5timesthenationalaverage.Morerecently,the“2002/2003RegionalHealthSurvey”suggestedthattheprevalencerateforDMamongadultshasincreasedto20%.(4)NationalandprovincialdataislesscommonlyavailablefortheMétisandnon-StatusAboriginalsandevenlessisknownabouttheimpactandburdenofdiabetesinthesepopulations,althoughsomeinformationisbeginningtoemerge.(5,6,29)

Type2diabetesamongAboriginalpeopleisalsooccurringatamuchyoungeragecomparedtothegeneralpopulation,withprevalenceratesof1.1%reportedinthe4-19-year-oldagegroupinnortheasternManitoba.(7)Thoughageneticpredispositiontotype2diabetesinOji-CreecommunitiesinManitobaandOntariohasbeenfound,(8)expertsagreethattheprimaryreasonsforincreasedprevalenceofdiabetesanditscomplicationsarelargelyduetothechangesinlifestylebroughtaboutbycolonization.(2,9)


CHAPTER 10DIABETES AND THE STATUS ABORIGINAL POPULATION IN ALBERTA

TheintentofthischapteristocomparetheincidenceandprevalenceofdiagnosedDMamongStatusAboriginalsandthegeneralpopulationofAlbertafrom1995-2007.Newtothe2009Alberta Diabetes Atlas isaseparateanalysisamongtheStatusAboriginalunder-20-year-oldpopulation,aswellasmortality,healthcareutilizationdata,andanalysesbyAlbertahealthzone.

METHODS

CasesofDMwereidentifiedusingtheAlbertaHealthandWellnessadministrativedatabasesbyapplyingtheNationalDiabetesSurveillanceSystem(NDSS)algorithm(see“BackgroundandMethods”chapter).StatusAboriginalpeoplewereidentifiedfromtheAlbertaHealthCareInsurancePlanCentralStakeholderRegistryfileandweredefinedasanyindividualresidinginAlbertaregisteredunderthefederalIndianAct.TheRegistryfilewassearchedfromJune1994-June2007andanyindividualinAlbertawithaStatusAboriginalidentifier(FirstNationsorInuit)wasclassifiedas“StatusAboriginal”withallotherindividualsclassifiedasthe“generalpopulation.”Aboriginalpeoplewhowerenotregistered,suchasAboriginalswithoutTreatystatusandMétis,wereincludedinthegeneralpopulationcomparisongroup.StatusAboriginalindividualswereincludedwhethertheywerelivingonoroffreserve.Thereareapproximately100,000StatusAboriginalpeople(62%onreserve)(10)and70,000MétispeoplelivinginAlberta.(11)

WhencalculatingtheprevalenceofDM,theproportionofStatusAboriginalpeoplewhohadDMwasdeterminedandcomparedtotheproportionofthegeneralpopulationwithDMatthesamepointintime.Thiswasrepeatedannuallyfrom1995-2007.AnincidentcaseofDMwasdefinedasapersonwhomettheNDSScriteriafordiabeteswithnodiabetesclaimsintheprior2years.IncidentrateswerecalculatedforStatusAboriginalandthegeneralpopulationwhodevelopedDMinthefiscalyears1995-2007.Allrateswereage-andsex-adjustedtotheAlbertapopulationfromthe2001CanadianCensus.

AnindependentanalysisofprevalenceandincidenceofDMamongtheunder-20-year-oldStatusAboriginalpopulationwasconducted.Giventhatthenumbersareverysmallamongthispopulation,onlyunadjustedcrudedataisprovided.

Mortalityandhealthcareutilization(generalpractitioner(GP)andspecialistencounters,emergencydepartment(ED)encountersandhospitalizations)datafortheyears1995-2007arealsopresentedinthischapter,whereratesarecomparedbetweenthetwopopulations(StatusAboriginalandthegeneralpopulation).

DatawaspresentedbyhealthzonesfordiabetesincidenceandprevalenceintheStatusAboriginalpopulation,forboththetotalpopulationandfortheunder-20-year-oldpopulationfor2007.Healthcareutilization(GPandspecialistencounters,EDencountersandhospitaldays)waspresentedforStatusAboriginalswithandwithoutdiabetes,andforStatusAboriginalscomparedtothegeneralpopulationfor2007.



10-1

10-4

10-5

Status AboriginalGeneral Population


Status Aboriginal Females

Status Aboriginal Males

General Population Females

General Population Males

12

10

8

6

4

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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Much higher than provincial rate

Higher than provincial rate

Close to provincial rate

Lower than provincial rate

Much lower than provincial rate

Calgary

South

North

Central

Edmonton

FINDINGS

Epidemiological Trends

Figure 10.1 Age- and Sex-Adjusted Diabetes Prevalence Rates, Among Status Aboriginal and General Populations, 1995-2007

In2007,theoverallage-andsex-adjustedprevalenceofDMintheAlbertaStatusAboriginalpopulationwas9.9%,increasing32%overthepast13yearsofobservation(Figure10.1).Thisisincontrasttothegeneralpopulationwhereprevalencehasincreased58%overthesametimeperiod.TheprevalenceofdiabeteswaslowerthantheprovincialrateforStatusAboriginalslivingintheNorthandEdmontonzones,closetotheprovincialrateintheCalgaryzone,andwasabovetheprovincialrateintheCentralandSouthzone(Figure10.2).TheprevalencewasconsistentlyhigherinStatusAboriginalfemalescomparedtomalesineachofthehealthzonesandwashighestinfemalesintheNorth,SouthandCentralzones(Figure10.3).

Figure 10.2 Age-Adjusted Status Aboriginal Diabetes Prevalence Rates for All Ages by Zone, 2007



10-1

10-4

10-5







12

10

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

12

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

12

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2

01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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s)

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TotalProvincial rate = 9.9

10-3

ZoneSouth Calgary Central Edmonton North

16

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8

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0

Rat

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AdjustedprevalenceandincidenceratesofDMwereroughlytwiceashighamongtheStatusAboriginalpopulationcomparedtothegeneralpopulation(Figure10.1and10.4).Since2001,however,theincidencerateappearstohavestabilizedfortheStatusAboriginalpopulationincomparisontothegeneralpopulation,whereincidencecontinuestoincrease.Whencomparingincreasesinincidenceratesstratifiedbysex,maleStatusAboriginalrateshavebeenincreasingfasterthanfemaleStatusAboriginalrates(19%versus6%).However,maleandfemalegeneralpopulationincidenceratesareincreasingthefastest(68%and56%)(Figure10.5).StatusAboriginalfemaleshavehigherincidenceratesinallthezones,exceptintheSouthwhereStatusAboriginalmalesarehigher(Figure10.6).

Figure 10.3 Age-Adjusted Status Aboriginal Diabetes Prevalence Rates by Zone, 2007

Figure 10.4 Age- and Sex-Adjusted Diabetes Incidence Rates, Among Status Aboriginal and General Populations, 1995-2007



10-1

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12

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

12

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01995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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Provincial rate = 8.210-6


18

16

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2

0

Rat

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Female

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Total

Figure 10.5 Age-Adjusted Diabetes Incidence Rates by Sex, Among Status Aboriginal and General Populations, 1995-2007

Figure 10.6 Age-Adjusted Status Aboriginal Diabetes Incidence Rates by Zone, 2007



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Status Aboriginal 1995

General Population 1995



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50

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DiabetesprevalenceamongStatusAboriginalpeopleandthegeneralpopulationincreasedintheolderagegroupsforbothmalesandfemales(Figure10.7and10.8).TheprevalenceofDMishigheramongStatusAboriginalfemalescomparedtomales,buttheoppositeistrueinthegeneralpopulation.TheprevalenceofdiabetesinStatusAboriginalswashighestintheSouthzoneacrossalltheagegroups(Figure10.9).TheCentralzonehadthesecond-highestrateinthe35andoveragegroupsandtheEdmontonandNorthzoneshadthelowestratesinthe50andoveragegroups.

Figure 10.7 Age-Specific Diabetes Prevalence Rates, Among Female Status Aboriginal and General Populations, 1995 and 2007

Figure 10.8 Age-Specific Diabetes Prevalence Rates, Among Male Status Aboriginal and General Populations, 1995 and 2007



10-10

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South

Calgary

Central

Edmonton

North

Figure 10.9 Age-Specific Status Aboriginal Diabetes Prevalence Rates by Zone, 2007

Comparableage-specificresultswereapparentwithrespecttotheincidenceofDMamongtheStatusAboriginalpopulation(Figure10.10and10.11).TheincidenceofDMisalsoassociatedwithincreasingage,withratesbeinghighestforStatusAboriginalfemalesfrom65-74yearsofage.Theseage-specificincidenceratesfortheStatusAboriginalpopulationshouldbeinterpretedwithcaution,especiallyintheoldestagecategories,becauseofasmallnumberofcases.ConfidenceintervalsaroundtheStatusAboriginalpopulationpointestimatesweretoolargetoincludeinthesefigures.

Figure 10.10 Age-Specific Diabetes Incidence Rates, Among Female Status Aboriginal and General Populations, 1995 and 2007



Rat

e pe

r 10

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ges

< 2

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ate

per

1000

(A

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0.35

0.30

0.25

0.20

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0.9

0.8

0.7

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0.5

0.4

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007



10-11

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5

01-9 10-19 20-34 35-49 50-64 65-74 75+

Rat

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Age Group (Years)





Figure 10.11 Age-Specific Diabetes Incidence Rates, Among Male Status Aboriginal and General Populations, 1995 and 2007

Trendsintheunder-20-year-oldStatusAboriginalpopulationwerealsogenerated.InFigure10.12,weseethatprevalenceofdiabetesinboththeStatusAboriginalandgeneralpopulationsareincreasingovertheobservationperiod.GeneralpopulationdiabetesprevalenceratesareconsistentlyhigherthanStatusAboriginalratesacrossallyears;however,thedifferencesbetweenthetwopopulationsarebecomingsmaller.Further,whentheStatusAboriginalpopulationisstratifiedbysex,weseethatprevalenceishighestamonggirlsfortheentiretimeperiod(Figure10.13).ThishigherprevalenceamonggirlsisalsoseeninallthehealthzonesexcepttheEdmontonzone,wheretheboysarehigher(Figure10.14).TheratesamonggirlswerehighestintheSouthandCentralzonesandlowestintheEdmontonzone.DifferencesbetweentheStatusAboriginalandgeneralpopulationsarebecomingsmallerovertimeduetoincreasingdiabetesincidenceratesintheunder-20-year-oldStatusAboriginalpopulationcomparedtothegeneralpopulation(Figure10.15).Cautionmustbetakenwheninterpretingthesefindingsbecausethecasecountsareverysmall.



Rat

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ate

per

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(A

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10-12

10-15

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0.30

0.25

0.20

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0.7

0.6

0.5

0.4

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007



10-11

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ays

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10-26

Age Group (Years)20-34 35-49 50-64 65-74 75+

12

10

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Status Aboriginal

General Population

Ratio

0.45

0.40

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0

Rat

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Female

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Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Therewas,intheStatusAboriginalunder-20-year-oldpopulation,atrendofincreasingcrudediabetesprevalenceandincidenceratesoverthe13-yeartimespanfrom1995-2007(Figure10.12and10.15).Again,cautionisneededwheninterpretingduetothesmallnumberofcasesandsubsequentdatavariability.

Figure 10.12 Crude Diabetes Prevalence Rates in the Under-20-Year-Old Population, Among Status Aboriginal and General Populations, 1995-2007

Figure 10.13 Crude Diabetes Prevalence Rates in the Under-20-Year-Old Status Aboriginal Population, 1995-2007



Rat

e pe

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ges

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ate

per

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(A

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007



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Provincial rate = 0.2710-14


1.0

0.9

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Rat

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Figure 10.14 Crude Status Aboriginal Diabetes Prevalence Rates in the Under-20-Year-Old Population by Zone, 2007

Figure 10.15 Crude Diabetes Incidence Rates in the Under-20-Year-Old Population, Among Status Aboriginal and General Populations, 1995-2007



Rat

e pe

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10-17

Deaths with Diabetes

Deaths without Diabetes

Rate Ratio



Rate Ratio

Age Group (Years)20-34 35-49 50-64 65-74 75+

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16

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)

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Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

10-16

Status Aboriginal with Diabetes

General Population with Diabetes

Status Aboriginal without Diabetes

General Population without Diabetes

MortalityratesfortheStatusAboriginalpopulationarehigherforthosebothwithandwithoutdiabetescomparedtomortalityratesinthegeneralpopulation.Infact,themortalityratesoftheStatusAboriginalpopulationwithoutdiabetesweresimilartothemortalityratesofthegeneralpopulationwithdiabetes.Thistrendwasconsistentovertime(1995-2007)(Figure10.16).ThelargestdropinmortalityratesoccurredintheStatusAboriginalpopulationwithdiabetes,whereratesdecreased50%overtheperiodofobservation;however,thesmallestdropinmortalityratesoccurredintheStatusAboriginalpopulationwithoutdiabetes(1%).Theseratesmustbeinterpretedwithcaution,however,duetothesmallnumberofcases.Thisisincontrasttothegeneralpopulation,whichhadreductionsinmortalityratesinboththeirdiabetesandnon-diabetespopulations(31%and20%respectively).Whenobservingage-specificmortalityratesforbothStatusAboriginalsandthegeneralpopulationofAlbertansin2007,rateswereconsistentlyhigheramongthosewithdiabetescomparedtothosewithoutdiabetes(Figure10.17and10.18).Themortalityrateratio(DMtonoDM)washigherforthegeneralpopulationcomparedtoStatusAboriginalsforallagegroups;however,thelargestrateratiooccurredintheyoungestagegroupinthegeneralpopulation(3.4),whiletherateratioremainedrelativelystableacrossallagesintheStatusAboriginalpopulation(1.0to1.3).

Figure 10.16 Age- and Sex-Adjusted Mortality Rates, Ages 20 and Over, Among Status Aboriginal and General Populations, 1995-2007



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Rate Ratio



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10-16





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Rate Ratio



Rate Ratio

Age Group (Years)20-34 35-49 50-64 65-74 75+

Rat

e pe

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)

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Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

10-16





Figure 10.17 Age-Specific Mortality Rates for the Status Aboriginal Population, Ages 20 and Over, 2007

Figure 10.18 Age-Specific Mortality Rates for the Entire Population (Status Aboriginal and General Populations), Ages 20 and Over, 2007



Ave

rage

Num

ber

of E

ncou

nter

s (A

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3.5

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io (

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3.5

3.0

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0

10-25

Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

rage

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1.2

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Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

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1.6

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10-20

Age Group (Years)20-34 35-49 50-64 65-74 75+

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Ave

rage

Num

ber

of E

ncou

nter

s (A

ges

>=

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3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Rat

io (

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us A

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gina

l:G

ener

al P

opul

atio

n)

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

10-25

Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

6

5

4

3

2

1

0

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

10-19

Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

25

20

15

10

5

0

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

10-20

Age Group (Years)20-34 35-49 50-64 65-74 75+

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Health Care UtilizationTheaveragenumberofspecialistencounterswassimilarfortheStatusAboriginalandthegeneralpopulationwithDM,forallagecategories(Figure10.19).However,theoppositewastruewithrespecttoGPvisits.TheStatusAboriginalpopulationhadmoreGPvisitscomparedtothegeneralpopulation,especiallyintheyoungeragegroups(Figure10.20).

Figure 10.19 Age-Specific Specialist Visits for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations, 2007

Figure 10.20 Age-Specific General Practitioner Visits for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations, 2007



Status Aboriginal

General Population

6

5

4

3

2

1

0

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

10-21


10-22


20

18

16

14

12

10

8

6

4

2

0

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

Status Aboriginal

General Population

Whenthedatawereexaminedbyhealthzone,theStatusAboriginalpopulationwithdiabeteshadasimilarnumberofvisitstospecialistsasthegeneralpopulationinmostzones,exceptCalgary(Figure10.21),buthadmoreGPvisitsthanthegeneralpopulationinallofthehealthzones(Figure10.22).TheaveragenumbersofvisitstospecialistswerehigherintheEdmontonandCalgaryzonesandlowestintheNorthzone(Figure10.21).TheoppositewasseeninthenumberofGPvisitsbyStatusAboriginalpeoplewithdiabetes,withtheNorth,CentralandSouthzoneshaveahighernumberofvisits(Figure10.22).

Figure 10.21 Age-Adjusted Average Number of Specialist Visits for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations by Zone, 2007

Figure 10.22 Age-Adjusted Average Number of GP Visits for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations by Zone, 2007



Diabetes

No Diabetes

6

5

4

3

2

1

0

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

10-23


Diabetes

No Diabetes

10-24


20

18

16

14

12

10

8

6

4

2

0

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

Similartothegeneralpopulation,theStatusAboriginalpopulationwithdiabeteshadahighernumberofspecialistandGPvisitsthantheStatusAboriginalpopulationwithoutdiabetes(Figures10.23and10.24).StatusAboriginalpeoplewithdiabeteshadmorevisitstoaspecialistintheEdmontonandCalgaryzonescomparedtothenon-metrozonesofSouth,NorthandCentralwhichhadahighernumberofGPvisits.

Figure 10.23 Age-Adjusted Average Number of Specialist Visits for Status Aboriginal Population, Ages 20 and Over by Zone, 2007

Figure 10.24 Age-Adjusted Average Number of GP Visits for Status Aboriginal Population, Ages 20 and Over by Zone, 2007



Ave

rage

Num

ber

of E

ncou

nter

s (A

ges

>=

20)

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

10-25

Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

6

5

4

3

2

1

0

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

10-19

Age Group (Years)20-34 35-49 50-64 65-74 75+

Ave

rage

Num

ber

of V

isits

(A

ges

>=

20)

25

20

15

10

5

0

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

10-20

Age Group (Years)20-34 35-49 50-64 65-74 75+

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Status Aboriginal

General Population

Ratio

Ave

rage

Num

ber

of D

ays

(Age

s>=

20)

Rat

io (

Stat

us A

bori

gina

l:G

ener

al P

opul

atio

n)

10-26

Age Group (Years)20-34 35-49 50-64 65-74 75+

12

10

8

6

4

2

0

3.0

2.5

2.0

1.5

1.0

0.5

0

Status Aboriginal

General Population

Ratio

0.45

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0

Rat

e pe

r 10

0 (A

ges

< 2

0)

10-13

Female

Male

Total

Year1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Thelargestdifferenceinhealthcareutilizationwasforemergencydepartment(ED)encounters,whereStatusAboriginalpeoplewithDMwere2to3timesmorelikelytovisitanemergencyroomthantheircounterpartsfromthegeneralpopulation(Figure10.25).

TheStatusAboriginaldiabetespopulationhadmorehospitaldaysonaveragecomparedtothegeneraldiabetespopulationwiththelargestdifferencesintheyoungeragegroups(Figure10.26).TheratiobetweentheStatusAboriginalandthegeneraldiabetespopulationswas1.5inthoseover75years.

Figure 10.25 Age-Specific Emergency Department Encounters for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations, 2007

Figure 10.26 Age-Specific Average Number of Hospital Days for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations, 2007



Status Aboriginal

General Population

10-27


4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Ave

rage

Num

ber

of E

ncou

nter

s (A

ges

>=

20)

10-28


5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Ave

rage

Num

ber

of D

ays

(Age

s >

= 2

0)

Status Aboriginal

General Population

AsimilarpatternwasseenwhenEDencountersandhospitaldayswerecomparedbyhealthzone(Figures10.27and10.28).StatusAboriginalpeoplewithdiabetesweremorelikelytovisitanEDcomparedtothegeneralpopulationwithdiabeteswithencountershighestintheruralzones(South,CentralandNorthzones)(Figure10.27).Thevariationwaslessamongthehealthzonesfordaysspentinhospital;however,theStatusAboriginalwithdiabeteshad1.5to2timesthenumberofdaysinhospitalcomparedtothegeneralpopulationwithdiabetes(Figure10.28).

Figure 10.27 Age-Adjusted Average Number of Emergency Department Encounters for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations by Zone, 2007

Figure 10.28 Age-Adjusted Average Number of Hospital Days for the Population with Diabetes, Ages 20 and Over, Among Status Aboriginal and General Populations by Zone, 2007



Diabetes

No Diabetes

10-29


4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Ave

rage

Num

ber

of E

ncou

nter

s (A

ges

>=

20)

Diabetes

No Diabetes

10-30


5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Ave

rage

Num

ber

of D

ays

(Age

s >

= 2

0)AStatusAboriginalpersonwithdiabeteswasmorelikelytovisitanEDcomparedtoaStatusAboriginalpersonwithoutdiabeteswiththehighestnumberofencountersintheNorth,CentralandSouthzones(Figure10.29).Thevariationwaslessamongthehealthzoneswhencomparingthenumberofdaysinhospital;however,theStatusAboriginalpersonwithdiabetesspent2to3timesthenumberofdaysinhospitalcomparedtotheStatusAboriginalpersonwithoutdiabetes(Figure10.30).

Figure 10.29 Age-Adjusted Average Number of Emergency Department Encounters for Status Aboriginal Population, Ages 20 and Over by Zone, 2007

Figure 10.30 Age-Adjusted Average Number of Hospital Days for Status Aboriginal Population, Ages 20 and Over by Zone, 2007



DISCUSSION

ConsistentwithnationalsurveydataandafewstudiesbasedonprimarydatacollectioninCanada(includingtheJamesBayCreeofQuebecandtheSandyLakeOji-CreeofOntario),(5,7,12-15)incidenceandprevalenceratesofDMforStatusAboriginalareapproximatelytwiceasmuchasthegeneralpopulationinAlberta.ThesefindingsaresimilartoareportfromOntario,wheretheNDSSdefinitionwasalsoappliedusingadministrativedata.(16)

Furthermore,StatusAboriginalsexperienceDMatanearlieragecomparedtothegeneralpopulation,afindingalsosupportedbypreviousworkinCanada.(2,7)

OurresultssuggestthatthedisproportionateincreaseofDMprevalenceamongStatusAboriginalpeopleinAlbertamaybereachingaplateau,asincidenceincreasedataslowerrateoverthepast13yearsintheStatusAboriginalcomparedtothegeneralpopulation.Thisfindingmustbetakenwithcaution,asamendmentstotheIndianActin1985arepotentiallyincreasingtheStatusAboriginaldenominator(BillC-31)and,conversely,somedescendantsofStatusAboriginalpersons(whostillhaveAboriginalancestry)arelosingtheirStatusthroughthe“threegenerations”rule.(17)Thereisnodatadescribinghowmuchofademographicchangehasoccurred,makingitimpossibletodiscerntheimpactonthecurrentDMrates.Alternatively,increasedawarenessandpreventionofdiabetesamongsttheStatusAboriginalpopulationinAlberta,throughfederallyfundedactivitiessuchastheAboriginalDiabetesInitiative,SLICK1,andtheprovinciallyfundedMDSi2,mayhaveplayedaroleinpreventionandthesubsequentslowedriseinDMratesamongStatusAboriginalpeople.

ThehigherprevalenceratesamongStatusAboriginalfemalescomparedtomalesparallelspreviousreports.(2,3)ThesesexdifferencesarecontrarytothegeneralCanadianpopulation,whereDMratesareslightlyhigherformales.(18)Inthecurrentanalysis,however,incidenceamongStatusAboriginalmalesisrisingatahigherratecomparedtofemales,suggestingthattheStatusAboriginalpopulationisbecomingmoresimilartothegeneralpopulation.Evenso,youngchildbearingagedwomenhadconcerningDMprevalencerates,twiceashighasthegeneralpopulation.ItisprobablethatsomeStatusAboriginalwomenintheseagegroupshadgestationaldiabetes,whichputsthematriskofsubsequentdevelopmentofDM.(16,19)

Theincreasingprevalenceandincidenceintheunder-20-year-oldStatusAboriginalpopulationisalarmingandsupportsthesuggestionthatDMisoccurringinyoungeragegroupsinAboriginalcommunities.(5,20)AccordingtotheFirstNationsandInuitRegionalHealthSurvey,themajority(53%)ofthosewithDMinAboriginalcommunitiesare40yearsofageandyounger.(3)ThecontinuedriseofobesityinAboriginalyouthislikelytheprimarydrivingforceofincreasingtype2diabetesratesintheyoungerpopulation.(2)

VerylittleinformationisavailablewithrespecttomortalityandDMamongCanadianAboriginalpeople.OurfindingsofhighermortalityratesamongStatusAboriginalpeoplewithDMisconsistentwithreportsfromBritishColumbiaadministrativevitalstatisticsthatshowedStatusAboriginalmalesandfemaleswithDMhadmortalityrates1.5and2.2

1 SLICK:ScreeningforLimbs,I-eyes,CardiacandKidneys(Aprovince-wideprogramaimedatreducingtheburdenofdiabetesonreserves).

2 MDSi:Mobilediabetesscreeninginitiative(Aprovince-wideprogramtoaddresstheincidenceofdiabetesinremoteandruraloffreservecommunities).



timeshigherthanthegeneralpopulationwithDM,respectively.(21)However,administrativedatafromOntarioshowedmortalityratesamongFirstNationspeoplewithDMdecreaseddramaticallyfrom1994-1999,and,infact,werelowerthanmortalityratesofthenon-FirstNationspopulationwithDMin1999.(13)AlthoughthereweremarkedimprovementsinmortalityforStatusAboriginalswithDMovertimeinthecurrentanalysis,overallrateswerestillsignificantlyhigherthanthegeneralpopulationin2007.

ConsistentwithasimilarreportonhealthcareutilizationinAlberta(22)andresultsfromotherprovinces,(23,24)wefoundStatusAboriginalpeoplewithDMweremuchmorelikelytohavemoredaysinthehospitalperyear,andweremorelikelytovisitaGPorEDthanthegeneralpopulationwithDM.Thismaybeexplained,inpart,byfindingsthathaveshownCanadianAboriginalpeoplewithDMexperiencerelatedcomplicationsmorefrequentlythanotherpopulations.(25-29)Althoughhealthcareutilizationisgreater,itappearstobelargelydrivenbyuseofacutecareservices.Thus,thequalityofcareandfollow-upmay,infact,besuboptimalformanyStatusAboriginalpeoplewithDMasculturalbarriers,geographicalbarriersandphysicianretention/shortageproblemsinruralcommunitieshavebeenshowntocompromisecare.(1,6,30)

TheDMincidenceandprevalenceratesamongtheStatusAboriginalpopulation,basedonDMdefinedfromadministrativedata,arelikelyanunderestimateforavarietyofreasons.First,alimitationofthisdefinitionistheinabilitytodetectundiagnoseddiabetes,whichiscommoninCanadianAboriginalcommunities.TheJamesBayCreeandSandyLakeOji-Creecommunitiesreportedundiagnoseddiabetesratesof2.5%and10.7%,respectively.(1,12)Second,manyAboriginalpeopleareuncomfortableintheWesternculturalmedicalenvironments,evenwhentheydoreceivediagnosticservices;therefore,theymaynotreturnforcare.Inaddition,medicalcareinremoteAboriginalcommunitiesisoftenprovidedbynursepractitioners,includingcareforDM.OnlyclaimsforDMrelatedvisitssubmittedbyphysiciansareincludedintheadministrativedataandcontributetothedefinitionofDMusedinthisAtlas.Hence,estimatesofDMarelikelyunderestimated.

SimilarwithotherprovincesinCanada,ratesofDMincidenceandprevalenceinAlbertaaretwiceashighamongStatusAboriginalpeoplecomparedtothegeneralpopulation.However,thistrendmaybeslowerasDMincidenceappearstobeincreasingataslowerrateamongtheStatusAboriginalpopulationcomparedtothegeneralpopulation.



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28. Zhang Y, Lee ET, Devereux RB, Yeh J, Best LG, Fabsitz RR, et al. Prehypertension, diabetes, and cardiovascular disease risk in a population-based sample: the strong heart study. Hypertension 2006;47(3):410-4.

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Chapter 10 Diabetes and the Status Aboriginal Population in Alberta

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